application for admission to the departmental contractor ... · contractor evaluation record part 1...

(Rev. 08/2011) of 6

Application for Admission to the Departmental Contractor List for Biomedical and Electronics Engineering Services –

Chromatography, Histopathology & Miscellaneous Pathology Equipment 1. Registered name of company/firm ____________________________________

Under Business Registration ____________________________________ Ordinance, Laws of Hong Kong ____________________________________

2. Registered address of company/firm ____________________________________ in Hong Kong under Business ____________________________________ Registration Ordinance, ____________________________________ Laws of Hong Kong ____________________________________ Telephone No. ____________________________________ Facsimile No. ____________________________________ 3. Date of formation or incorporation ____________________________________ under Companies Ordinance, Laws of Hong Kong 4. Date of original registration under ____________________________________ Business Registration Regulations, Business Registration Ordinance, Laws of Hong Kong. 5. Business Registration Certificate No. ___________________________________

Date of Expiry under ___________________________________ Business Registration Regulations, Business Registration Ordinance, Laws of Hong Kong. 6. The company/firm is * (a) a body corporate, registered under the Companies Ordinance, or * (b) a partnership (unincorporated), or * © a sole proprietorship (unincorporated).

(Rev. 08/2011) of 6

7. Previous name(s) of company/firm with dates, if any. 8. Name(s) of ultimate holding company, parent company, subsidiary or associated companies etc. 9. Names of directors/managers and length of service with the applicant Name Designation Length of Service 10. Name and designation of person(s) who will sign contracts with Government Name Designation 11. Banker(s) to whom reference may be made Name Address 12. Address of trading office ____________________________________ (if different from registered ____________________________________ address) and approximate ____________________________________ area of office ____________________________________ Telephone No. ____________________________________ Facsimile No. ____________________________________ 13. Address and approximate area ____________________________________ of Workshop/Office ____________________________________ Telephone No. ____________________________________ Facsimile No. ____________________________________

(Rev. 08/2011) of 6

14. (a) Name, qualifications, experience, training received, and length of service of professional/ technical staff.

(b) Direct employed work-force. Trade/Stream/Grade No. 15. Please provide details of development facilities and equipment including quantity and make/model/capacity of each. For test equipment please also state where and when they were last calibrated.

Item Description Quantity Make/Model Capacity Calibration Where Date

1. Digital Voltage Meter

(DVM)

2. Electrical Safety Tester

3.

4.

5.

16. Relevant Projects Handled

The company/firm is required to state below briefly his previous experience in execution of related projects (inclusive of supply / installation / maintenance types) as well as particulars of the projects currently being executed. The projects quoted here shall be located in the territories of Hong Kong and may be available for inspection. Description/Nature of Project Client Construction Period Contract Sum

(Rev. 08/2011) of 6

17. Training State whether training facilities are available – YES/NO *

If the answer to the above is YES, please state how training of Government employees would be provided as part of a contract.

If the answer to the above is NO, please state if any alternative arrangement could be made if training is required in a contract.

18. Documentation

Please state if detailed documentations, e.g. circuit diagrams, fault diagnostic charts, operation flow charts, programme codes, etc. will be made available to Government in respect of all equipment and software supplied and installed – YES/NO* If the answer to the above is NO, please state restrictions and limitations.

19. Maintenance

Please state if the company/firm will be willing to take up maintenance works – YES/NO * If the answer to the above is YES, please state the number and grade of staff deployed for maintenance activities.

If the answer to the above is NO, please state if any alternative arrangement could be

made to provide the maintenance services for the equipment and software supplied in a contract.

(Rev. 08/2011) of 6

20. Spare Holding Policies Please state the policies on spare holdings relating to maintenance in terms of the following :- (a) For particular installations (quote examples)

(b) For general purposes 21. Quality, Environmental and OH&S

Please complete the Quality, Environmental and OH&S Checklist at Appendix 1. 22. Authorized Agency

Please state any authorized agency, or representation of the manufacturer; in HKSAR Documentary proof such as authorized agency agreements shall be enclosed.

23. Autopay Arrangement Please state if autopay arrangement has been made with the Electrical and Mechanical

Services Trading Fund. If no or not sure, please fill in the "AUTHORITY FOR PAYMENT TO A BANK" Form (GF179A) as attached in Appendix 2.

YES/NO * 24. Government’s Purchasing Card Programme Please provide the Purchasing Card Merchants information under the government’s

Purchasing Card Programme.

Purchasing Card Service Provider: ____________________________________ ____________________________________

Merchant Category Code (MCC): ____________________________________

(Rev. 08/2011) of 6

25. I certify that all information provided is true and complete to the best of my knowledge. The following supporting documents are forwarded herewith :- (i) A copy of the Business Registration Certificate. (ii) * A copy of Memorandum and Articles of Association. * A copy of Application for Registration of Business (Partnership) * A copy of Application for Registration of Business (Sole Proprietorship)

under Business Registration Regulations. (iii) * Details of works carried out and currently in hand. (iv) An organization chart. (v) Office layout plan with principal dimensions and positions of major development

facilities. (vi) * A copy of the Certificate of Incorporation under Companies Ordinance (vii) * Authorized Agency Agreement (viii) Quality, Environmental and OH&S Checklist (ix) * "AUTHORITY FOR PAYMENT TO A BANK" Form (GF179A)

Date ____________________ Signed ____________________________ Name ____________________________

Designation ____________________________ * -- Delete as appropriate

EMSD - Health Sector Division (HSD) Appendix 1

IMS-3 (Issue 6/02) Page 1 of 4

Contractor Evaluation Record

Part 1 – Quality, Environmental and Occupational Health & Safety Checklist (to be completed by contractor / supplier)

Please tick below one of the 4 descriptions which most closely fits your current status; otherwise, please describe your current status being asked for in the space under “Remarks”. Q1 1 2 3 4 Health and safety policy Health and safety

policy under preparation

Commit to comply with HSD’s OH&S Policy

Health and safety policy available and commit to comply with HSD’s OH&S Policy

Sound health and safety policy (fulfilling F&IU(SM) Reg. requirement)

Remarks Please attach a copy of Health and Safety Policy, if available

Q2 1 2 3 4 Health and safety manual or plan

Only Safety Policy but no health and safety plan

Under preparation and draft health and safety plan available.

Safety plan available.

Comprehensive health and safety plan comply with recognize standard (e.g. F&IU(SM) Reg. or OHSAS 18001: 1999)

Remarks Please specify the standard to which the OH&S plan complies with.

Q3 1 2 3 4 Safety organization Safety organization

included only line supervision staff

Safety organization included only line supervision staff & management staff

Safety organization included line supervision staff, management staff and company top management

Safety organization included line supervision staff, management staff, safety profession and company top management

Remarks Please attach a copy of organization chart, if available

Q4 1 2 3 4 Safety personnel Only Safety

Supervisor appointed on for the project.

Assistant Safety Officer or full time Safety Supervisor appointed.

In addition, part RSO employed for the project

Full time RSO for the project

Remarks Please specify number of Safety Supervisor and Register Safety Officer employed.

Q5 1 2 3 4 Occupational health & safety training to staff/worker

Training is being arranged.

Only “Green Card” Training.

In addition other relevant safety and health training provided to staff/workers

A training plan available, and relevant safety and health training to workers are specified.

Remarks Please specify (a) Percentage of staff/worker with “Green Card”. (b) Type of safety training other than Green Card, if available





Please tick below one of the 4 descriptions which most closely fits your current status; otherwise, please describe your current status being asked for in the space under “Remarks”. Q6 1 2 3 4 Past year accidents record Only number of

accident recorded. Accident statistic available but no target for accident rate

Accident rate above their target accident rate

Accident rate below their target accident rate

Remarks Please specify number of accident in past 12 month and the target accident rate.

Q7 1 2 3 4 Record of fatal accident More than one fatal

accident in the past 12 months

Detail investigation to identify the probable cause of the accident.

In addition, prompt arrangement to prevent similar accident from happening.

No fatal accident record

Remarks Please specify number of fatal accident in past 12 months, if available

Q8 1 2 3 4 Conviction record in past 24 months related to violation of statutory and regulatory requirements including any occupational health and safety related or environmental related legislation

More than 3 convictions in past 24 months

Less than 3 but more than 1 conviction in past 24 months

Only 1 conviction in past 24 months

No conviction in past 24 months

Remarks Please specify number and details of conviction in past 24 months, if available.

Q9 1 2 3 4 Job Hazard Analysis / Risk Assessment (JHA/RA)

Committed to comply with the recommendation stated in EMSD’s Risk Assessment Report

A written procedure or methodology for JHA/RA is available.

JHA/RA would be conducted for high-risk activities.

Competent / Qualified person(s) is/are employed to conduct JHA/RA.

Remarks Please provide procedure or methodology for JHA/RA, if available.

Q10 1 2 3 4 Method Statement Committed to follow

EMSD’s work instructions.

Only work procedure breakdown would be prepared

Method Statement with detail work procedure breakdown with safety and health control measure would be prepared

Comprehensive Method Statement would be developed based on the result of JHA/RA.

Remarks





Please tick below one of the 4 descriptions which most closely fits your current status; otherwise, please describe your current status being asked for in the space under “Remarks”. Q11 1 2 3 4 Quality Management System

Planning to implement a quality management system

Work has commenced to develop a quality management system

A quality management system in place, but not or not yet certified by accreditation body

A quality management system in place and has been certified to a recognized standard, e.g. ISO 9001

Remarks Please specify the standard used to develop the quality management system.

Q12 1 2 3 4 Environmental Management System

Planning to implement an environmental management system

Work has commenced to develop an environmental management system

An environmental management system in place, but not or not yet certified by accreditation body

An environmental management system in place and has been certified to a recognized standard, e.g. ISO 14001

Remarks Please specify the standard used to develop the environmental management system.

Completed for and on behalf of the Contractor / Supplier by:

Signature :

Name :

Title :

Date : Company Chop



Contractor Evaluation Record Part 2: For EMSD Use Only

Summary of Marks

Marking Scheme: Mark 0 1 2 3 4

For questions Q1 to Q12

Not answered

Answer with “1”

Answer with “2”

Answer with “3”

Answer with “4”

For other criteria Poor Satisfactory Fair Good Excellent

Questions / Criteria Marks for Contractor / Supplier under Evaluation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8 (a)

Q9

Q10

Q11 (b)

Q12 (c)

Experience / Competence

Reputation (d)

Lead Time / Delivery (e)

Cooperation / Attitude (f)

Total =

For Supplier only: (a)+(b)+(c)+(d)+(e)+(f) = Evaluation Result

Name of Contractor / Supplier : ______________________________________________________ Evaluation Result #

# Conditions:

: Satisfactory / Unsatisfactory* as Contractor / Supplier*

For Contractor, the total mark shall be at least 26 for “satisfactory”. For Supplier , the sum (a)+(b)+(c)+(d)+(e)+(f) shall be at least 12 for “satisfactory”.

* Delete as appropriate

Evaluated by: _____________________________ Date: ________________ Approved by: _____________________________ Date: ________________

Appendix 2

application for admission to the departmental contractor ... · contractor evaluation record part 1...

Documents